Original ArticleThe Safety and Efficacy of CT-Guided, Fluoroscopy-Free Vertebroplasty in Adult Spinal Deformity Surgery
Introduction
Proximal junction kyphosis (PJK) is one of the most common complications after long-segment fusions for adult spinal deformity (ASD). It results from increased load and motion at the upper instrumented vertebrae (UIV) and unfused adjacent segment (UIV+1). It can be caused directly by proximal vertebral fractures, screw pull-out, or failure of the posterior longitudinal ligament at the top of the construct.
Published rates of PJK after thoracolumbar fusion vary from 11% to 41%.1, 2, 3, 4, 5 An analysis of 440 consecutive adult spinal deformity patients at our own institution revealed a PJK rate of 36%, with 15% requiring revision surgery.6 Revision surgery for PJK is associated with an average direct cost of more than $55,000 at our institution7 and $77,000 at another hospital.8 Known risk factors for PJK include excessive preoperative thoracic kyphosis, preoperative proximal junctional angle greater than 10 degrees, change in lumbar lordosis greater than 30 degrees, high preoperative pelvic tilt, and pelvic incidence greater than 55 degrees.3, 4
Given the high frequency, cost, and morbidity of PJK, deformity surgeons use multiple techniques to prevent PJK, such as ligamentoplasty and vertebroplasty. These techniques may require substantial accumulated radiation exposure to the surgical team using fluoroscopic guidance.9 Cement augmentation increases vertebral body stiffness and has been used successfully for many years to treat osteoporotic fractures.10, 11, 12, 13, 14, 15 Recently, vertebroplasty has been used to prevent vertebral compression fracture and reduce PJK in long-segment posterior spinal fusions.6, 7, 8, 16, 17, 18 Although data are somewhat limited, these studies suggest that vertebroplasty is an effective adjunct for preventing PJK after spinal deformity surgery.
To our knowledge, all prior studies use real-time fluoroscopy to perform vertebroplasty. In this report, we present a novel technique for computed tomography (CT)-guided, fluoroscopy-free vertebroplasty, and we analyze the safety and efficacy of this procedure across 118 consecutive adult patients with spinal deformity. We compare patients these with a historical control group of 253 adult patients at our own institution who underwent spinal deformity surgery with the same attending surgeons before the implementation of this vertebroplasty technique.
Section snippets
Methods
We performed a retrospective analysis of all patients who underwent vertebroplasty-augmented posterior spinal fusion with the senior authors (V.D. and C.P.A.) from January 2013 to December 2016. This study was approved by the University of California, San Francisco Institutions Review Board (CHR#17-22152). We selected these dates because the senior authors began using cement augmentation at the UIV and the UIV+1 for all spinal deformity patients with fusions ending in the distal thoracic spine
Results
We identified 118 patients (77 female, 41 male) who underwent posterior spinal instrumentation with fluoroscopy-free vertebroplasty during 2013–2016. The mean age was 67 years (±9.0), and the majority of patients had either Medicare (n = 79; 67%) or private insurance (n = 36; 31%); 79% of patients were white (n = 93), and all patients were either ASA grade 2 (n = 65; 55%) or grade 3 (n = 53; 45%; Table 1). Vertebroplasty patients were slightly older than those in the control group who did not
Discussion
Reducing proximal junctional kyphosis after adult spinal deformity surgery remains a challenge for all spine surgeons. This study demonstrates that performing fluoroscopy-free vertebroplasty is not only safe; it is also associated with reduced rates of postoperative proximal junctional kyphosis. The rate of proximal junctional kyphosis in the vertebroplasty patients in this study is 14%, significantly lower than the 40% rate at our own institution before the development of the vertebroplasty
Conclusion
After controlling for patient and other surgical factors in multivariate analyses, vertebroplasty was significantly associated with lower rates of PJK and PJK requiring reoperations. Our novel vertebroplasty technique is safe, and it eliminates the need for additional fluoroscopy in cases already using intraoperative CT imaging to verify screw placement. In addition, it is an effective technique for reducing PJK in adult spinal deformity surgery when compared with historical institutional
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Cited by (9)
Complications and Avoidance in Adult Spinal Deformity Surgery
2023, Neurosurgery Clinics of North AmericaImproving outcomes in adult spinal deformity surgery
2023, Seminars in Spine SurgeryThe efficacy of prophylactic vertebroplasty for preventing proximal junctional complications after spinal fusion: a systematic review
2022, Spine JournalCitation Excerpt :Prophylactic VP introduces the risk of CE and other complications, though it is unclear how frequently these complications occur. Zygourakis et al. [19] found that just less than half of patients who underwent prophylactic VP experienced CE, with most of these patients reporting noticeable effects of the extravasation. However, it should be noted that Zygourakis et al. used a novel vertebroplasty technique involving computed tomography instead of commonly used real-time fluoroscopy, which may have affected their results.
State of the Evidence for Proximal Junctional Kyphosis Prevention in Adult Spinal Deformity Surgery: A Systematic Review of Current Literature
2022, World NeurosurgeryCitation Excerpt :However, the reoperation rate for PJFx was lower in the vertebroplasty group (3.6% vs. 14.3%).18 Zygourakis et al.19 reported that using computed tomography-guided prophylactic vertebroplasty decreased the PJK rate from 40% in the historic control group to 14% in the vertebroplasty group, with a corresponding reduction in reoperation rates from 17% to 3% in the control and vertebroplasty groups, respectively. Two studies examining prophylactic vertebroplasty using polymethylmethacrylate (PMMA) reported a decrease in the PJK and PJF rates.17,20
Navigated Cementoplasty With O-Arm and Surgivisio: An Ambispective Comparison With Radiation Exposure
2022, International Journal of Spine Surgery
Conflict of interest statement: Corinna C. Zygourakis has received travel grants from Nuvasive and Globus to attend resident education courses; Clifford L. Crutcher has received trabvel grants from Corelink and Stryker to attend resident educational courses; Vedat Deviren is a consultant for and receives research grants and royalties from Nuvasive; Christopher P. Ames receives research grants from DePuy Synthes Spine, is a consultant for DePuy, Medtronic, and Stryker, is a shareholder of stock in Baxano and Doctor's Research Group, and receives royalties from Aesculap and Biomet Spine.